Patient Number
Item
Patient Number
text
C1830427 (UMLS CUI [1])
Centre Number
Item
Centre Number
text
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Date of Report
Item
Date of Interview
date
C1302584 (UMLS CUI [1])
Limb movement
Item
1. a desire to move the limbs usually associated with paresthesias or dysesthesias
boolean
C0596840 (UMLS CUI [1])
Motor Restlessness
Item
2. motor restlessness (during wakefulness does the patient move the limbs in attempt to relieve the discomfort)
boolean
C0700075 (UMLS CUI [1])
Symptoms at rest
Item
3. symptoms worse or exclusively present at rest with at least partial and temporal relief by activity
boolean
C1457887 (UMLS CUI [1,1])
C0035253 (UMLS CUI [1,2])
Worsening in night
Item
4. symptoms worse in the evening or night
boolean
C0332271 (UMLS CUI [1,1])
C0240526 (UMLS CUI [1,2])
Comorbidity
Item
Is the subject suffering from or has he/she ever suffered from any significant medical or surgical condition?
boolean
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Date of First Diagnosis
Item
Year of first diagnosis
date
C2316983 (UMLS CUI [1])
Past Medical History
Item
Past
boolean
C0262926 (UMLS CUI [1])
Ongoing
Item
Ongoing
boolean
C0549178 (UMLS CUI [1])
Smoking Status
Item
Is the subject a smoker?
boolean
C1519386 (UMLS CUI [1])
Smoking Years
Item
Number of years the subject has been a smoker?
float
C1277691 (UMLS CUI [1])
Cigarettes per day
Item
Average number of cigarettes smoked per day?
float
C3694146 (UMLS CUI [1])
Tobacco product
Item
Please state what type of tobacoo product (e.g. pipe, cigar, chewing tobacco or cigarette)
text
C3166496 (UMLS CUI [1])
Pharmacotherapy for RLS
Item
Has the patient taken any pharmacotherapy medication for treatment of RLS?
boolean
C0013216 (UMLS CUI [1,1])
C0035258 (UMLS CUI [1,2])
Drug name
Item
Drug Name (Trade Name Preferred)
text
C0013227 (UMLS CUI [1])
Start Date
Item
Start Date (be as precise as possible)
date
C0808070 (UMLS CUI [1])
End Date
Item
End Date
date
C0806020 (UMLS CUI [1])
Ongoing
Item
or if Continuing mark box
boolean
Item
Did the patient respond to the treatment? (mark one)
text
C0521982 (UMLS CUI [1])
Code List
Did the patient respond to the treatment? (mark one)
CL Item
Unknown (Unknown)
Item
Did the patient tolerate the treatment? (mark one)
text
C3274448 (UMLS CUI [1])
Code List
Did the patient tolerate the treatment? (mark one)
CL Item
Unknown (Unknown)
Date of Measurement
Item
Date
date
C0011008 (UMLS CUI [1])
Semi-supine Systolic Blood Pressure
Item
Semi-supine Blood Pressure: Systolic (Instructions: Semi-supine measurements will be made after the patient has been resting semi-supine for at least 10 min & erect measuremnts will be taken after the patients has been erect for a period of 1 min. - The blood pressure curff must be placed on the same arm throughout the study. - The same sutdy nurse/operator should conduct all the blood pressure measurements for each clinic visit. - Ideally, the same study nurse/operator should conduct ALL the blood pressure measurements for each patient throughout the study.
float
C0522019 (UMLS CUI [1,1])
C0871470 (UMLS CUI [1,2])
Semi-supine Diastolic Blood Pressure
Item
Semi-supine Blood Pressure: Diastolic (Instructions: Semi-supine measurements will be made after the patient has been resting semi-supine for at least 10 min & erect measuremnts will be taken after the patients has been erect for a period of 1 min. - The blood pressure curff must be placed on the same arm throughout the study. - The same sutdy nurse/operator should conduct all the blood pressure measurements for each clinic visit. - Ideally, the same study nurse/operator should conduct ALL the blood pressure measurements for each patient throughout the study.)
float
C0522019 (UMLS CUI [1,1])
C0428883 (UMLS CUI [1,2])
Semi-supine Heart Rate
Item
Semi-supine Heart Rate (Instructions: Semi-supine measurements will be made after the patient has been resting semi-supine for at least 10 min & erect measuremnts will be taken after the patients has been erect for a period of 1 min. - The blood pressure curff must be placed on the same arm throughout the study. - The same sutdy nurse/operator should conduct all the blood pressure measurements for each clinic visit. - Ideally, the same study nurse/operator should conduct ALL the blood pressure measurements for each patient throughout the study.)
float
C0522019 (UMLS CUI [1,1])
C0018810 (UMLS CUI [1,2])
Erect Systolic Blood Pressure
Item
Erect Blood Pressure: Systolic (Instructions: Semi-supine measurements will be made after the patient has been resting semi-supine for at least 10 min & erect measuremnts will be taken after the patients has been erect for a period of 1 min. - The blood pressure curff must be placed on the same arm throughout the study. - The same sutdy nurse/operator should conduct all the blood pressure measurements for each clinic visit. - Ideally, the same study nurse/operator should conduct ALL the blood pressure measurements for each patient throughout the study. Repeat the erect measurement IMMEDIATELY if reading is technically invalid & discard inaccurate data, enter the repeat data in the CRF.)
float
C0522014 (UMLS CUI [1,1])
C0871470 (UMLS CUI [1,2])
Erect Diastolic Blood Pressure
Item
Erect Blood Pressure: Diastolic (Instructions: Semi-supine measurements will be made after the patient has been resting semi-supine for at least 10 min & erect measuremnts will be taken after the patients has been erect for a period of 1 min. - The blood pressure cuff must be placed on the same arm throughout the study. - The same sutdy nurse/operator should conduct all the blood pressure measurements for each clinic visit. - Ideally, the same study nurse/operator should conduct ALL the blood pressure measurements for each patient throughout the study. Repeat the erect measurement IMMEDIATELY if reading is technically invalid & discard inaccurate data, enter the repeat data in the CRF.)
float
C0522014 (UMLS CUI [1,1])
C0428883 (UMLS CUI [1,2])
Erect Heart Rate
Item
Erect Heart Rate (Instructions: Semi-supine measurements will be made after the patient has been resting semi-supine for at least 10 min & erect measuremnts will be taken after the patients has been erect for a period of 1 min. - The blood pressure cuff must be placed on the same arm throughout the study. - The same sutdy nurse/operator should conduct all the blood pressure measurements for each clinic visit. - Ideally, the same study nurse/operator should conduct ALL the blood pressure measurements for each patient throughout the study. Repeat the erect measurement IMMEDIATELY if reading is technically invalid & discard inaccurate data, enter the repeat data in the CRF.)
float
C0522014 (UMLS CUI [1,1])
C0018810 (UMLS CUI [1,2])
Date of ECG
Item
Date
date
C2826640 (UMLS CUI [1])
Time of ECG
Item
Actual Time
time
C0040223 (UMLS CUI [1,1])
C0013798 (UMLS CUI [1,2])
Heart Rate
Item
Heart Rate
float
C0018810 (UMLS CUI [1])
PR Interval
Item
PR
float
C0429087 (UMLS CUI [1])
QRS Interval
Item
QRS
float
C1880451 (UMLS CUI [1])
QTC Interval
Item
QTC
float
C0855331 (UMLS CUI [1])
ECG clinically significant
Item
ECG clinically significant?
boolean
C1623258 (UMLS CUI [1,1])
C2985739 (UMLS CUI [1,2])
ECG Comment
Item
Comments*
text
C0947611 (UMLS CUI [1,1])
C1623258 (UMLS CUI [1,2])
Date of Collection
Item
Exact date of blood sampling
date
C0005834 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Time of Collection
Item
Exact time of blood sampling
time
Comment
Item
Comments:
text
C0947611 (UMLS CUI [1,1])
C0008000 (UMLS CUI [1,2])
C0947611 (UMLS CUI [2,1])
C0474523 (UMLS CUI [2,2])
Clinical Chemistry & Haematology: Abnormal Findings
Item
Are there clinically significant abnormal values?
boolean
C1704258 (UMLS CUI [1,1])
C0008000 (UMLS CUI [1,2])
C1704258 (UMLS CUI [2,1])
C0474523 (UMLS CUI [2,2])
Date of Drug Screening
Item
Exact date of sampling
date
C0011008 (UMLS CUI [1,1])
C0202274 (UMLS CUI [1,2])
Time of Drug Screeing
Item
Exact time of sampling
time
C0040223 (UMLS CUI [1,1])
C0202274 (UMLS CUI [1,2])
Contraindicated Drug
Item
Were there any contra-indicated drugs detected?
boolean
C1444657 (UMLS CUI [1,1])
C4036061 (UMLS CUI [1,2])
Type of Drug
Item
Type of Drug
text
C0457591 (UMLS CUI [1])
Drug Screening Comment
Item
Comment
text
C0202274 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Date of Urinanalysis
Item
Exact date of urine sampling
date
C0042014 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Time of Urinanalysis
Item
Exact time of urine sampling
time
C0042014 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Urinanalysis abnormality
Item
Are there clinically significant abnormal values?
boolean
C0042014 (UMLS CUI [1,1])
C1704258 (UMLS CUI [1,2])
Urine pH
Item
Results for dip stick test: pH
text
C0042044 (UMLS CUI [1])
Urine pH: Clinically Significant
Item
Urine pH: Clinically Significant
boolean
C0042044 (UMLS CUI [1,1])
C2826633 (UMLS CUI [1,2])
Urine pH: Comment
Item
Urine pH: Comments
text
C0947611 (UMLS CUI [1,1])
C0042044 (UMLS CUI [1,2])
Urine Protein
Item
Results for dip stick test: Protein
text
C0262923 (UMLS CUI [1])
Urine Protein: Clinically Significant
Item
Urine Protein: Clinically Significant
boolean
C2826633 (UMLS CUI [1,1])
C0262923 (UMLS CUI [1,2])
Urine Glucose
Item
Results for dip stick test: Urine Glucose
text
C0004076 (UMLS CUI [1])
Urine Glucose: Clinically Significant
Item
Urine Glucose: Clinically Significant
boolean
C0004076 (UMLS CUI [1,1])
C2826633 (UMLS CUI [1,2])
Urine Glucose: Comment
Item
Urine Glucose: Comments
text
C0004076 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Urine Bilirubin
Item
Results for dip stick test: Urine Bilirubin
text
C0042040 (UMLS CUI [1])
Urine Bilirubin: Clinically Significant
Item
Urine Bilirubin: Clinically Significant
boolean
C0042040 (UMLS CUI [1,1])
C2826633 (UMLS CUI [1,2])
Urine Bilirubin: Comments
Item
Urine Bilirubin: Comments
text
C0042040 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Hematuria
Item
Results for dip stick test: Urine Blood
text
C0018965 (UMLS CUI [1])
Hematuria: Clinically Significant
Item
Urine Blood: Clinically Significant
boolean
C0018965 (UMLS CUI [1,1])
C2826633 (UMLS CUI [1,2])
Hematuria: Comments
Item
Blood Urine: Comments
text
C0018965 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Pregnancy Test
Item
Was a pregancy test carried out?
boolean
C0032976 (UMLS CUI [1])
Reason
Item
If 'NO', please specify reason:
text
C0392360 (UMLS CUI [1])
Date of Pregnany Test
Item
If 'YES', please indicate date of result:
date
C0011008 (UMLS CUI [1,1])
C0032976 (UMLS CUI [1,2])
Item
If 'YES', please indicate the result:
text
C0427777 (UMLS CUI [1])
Code List
If 'YES', please indicate the result:
CL Item
Positive (Positive)
CL Item
Negative (Negative)